- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $537.03 / $1,584.89
| Professional | | $309.03 | $537.03 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $141.25 / $302.00
| Professional | 26 | $81.28 | $141.25 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $389.05 / $707.95
| Professional | TC | $223.87 | $389.05 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $537.03 / $1,047.13
| Professional | | $389.05 | $537.03 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $125.89 / $218.78
| Professional | 26 | $104.71 | $125.89 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $288.40 / $363.08 / $489.78
| Professional | TC | $288.40 | $363.08 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $776.25 / $1,023.29
| Professional | | $416.87 | $776.25 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $151.36 / $229.09
| Professional | 26 | $95.50 | $151.36 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $588.84 / $812.83
| Professional | TC | $295.12 | $588.84 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $524.81 / $758.58
| Professional | | $389.05 | $524.81 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $123.03 / $181.97
| Professional | 26 | $97.72 | $123.03 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $281.84 / $407.38 / $616.60
| Professional | TC | $281.84 | $407.38 | $616.60 |